For a man who once wrestled a runaway cow to the ground, Ali (not his real name) appears timid and tranquil. The notoriety he gained on the bustling narrow streets of Newtown, a suburb of Accra, is something he is trying to shake off. His “rebirth” began four months earlier when he committed to never again taking Tramadol, a synthetic opioid used to moderate severe pain.
Africa remains one of the regions least served with effective pain relief medicine and although Tramadol is not the strongest of analgesics, it is a darling on prescription lists. That’s because unlike other opioids such as methadone and fentanyl, Tramadol is not internationally regulated, hence it is cheap and readily available for patients. Doctors prescribe Tramadol in cases of post-surgical pain, bone deficiencies and cancer and the medical charity Médecins Sans Frontières (Doctors Without Borders) classifies it among its ‘essential drugs’ list.
However, in the last decade, the continent has seen a significant rise in the non-medical use of Tramadol, which produces similar effects to the “high” caused by heroin. Such is the popularity of Tramadol local Ghanaian users have it the nickname “Tramore” similar to the offical brand name, Tramal.
In Gabon, where Tramore is known as “Kobolo” high school teachers are struggling to contain a crisis. Upon request, some of Khartoum’s roadside tea-sellers are even known to drop the painkiller in a cup of tea. In January, Afrobeats rapper Olamide was forced to defend himself after Nigeria’s broadcasting regulators declared his hit song ‘Science Student‘ (which makes a reference to Tramadol) “unfit for broadcast” because of “the profligate mention and the subtle promotion of illegal drugs.” The singer (real name: Olamide Adedeji) argued he’s bringing awareness to a much ignored problem that’s spreading with young Nigerians on Lagos’ tough streets.
In Egypt, which has significant data about its national crisis, a 2015 study by the ministry of health and the UNODC found 100,000 people dependent on opioids with half of that number dependent on Tramadol [pdf p.6]. Again, 68% of patients seeking addiction treatment in government facilities did so because of Tramadol addiction [pdf p.6].
Ali first popped Tramore in 2007 after he started work at Accra’s Timber Market.”It was very hard work and Tramore helped him and his colleagues (who introduced him to it) work longer hours by numbing the pain that came with carrying heavy wood —the kind of numbness a person would need in order to confront a cow. Some farmers are known to give Tramadol to cattle who are then able to plough large tracts of fields at a go or walk long distances in search of pasture under the sweltering heat.
The popularity of Tramadol on the continent is not only for its pain relief. “I used to take it when I want to have sex. It gives me more strength to have sex,” a suddenly-shy Ali says. Researchers believe Tramadol’s aphrodisiac properties could stem from its antagonism of serotonin receptors hence delaying ejaculation.
Mumbai to Cotonou
Tramadol’s user base has become a draw factor for trans-African organized crime syndicates who smuggle Tramadol across Africa’s porous borders. After Egypt (where in 2012 alone, 620 million tablets were seized [pdf p.3]) increased its clampdown on illegal importation, Libya (because of political instability) became the new destination.
Last November, Italian authorities seized a Tramadol shipment from India to Libya worth 50 million euros. Six months prior, they had seized a shipment worth 75 million euros. Authorities believe they were destined for ISIS bases in Libya. The Cotonou port of the tiny country of Benin has also become the latest hub largely due to that country’s relatively weak Customs officials. In 2015, 40 million tablets of Tramadol was seized there. The following year, the US State Department declared Benin, a country of just 11 million people, the world’s second largest destination for Indian Tramadol.
From Benin, the tablets make their way across West Africa and the Sahel regions into the hands of terror groups such as al Qaeda, who have taken to the illicit trade in Tramadol as a source of funding, according to the United Nations Office on Drugs and Crime.
Tramadol has been found in the pockets of captured Boko Haram fighters as well as those who were killed in combat and suicide bombings. So while Tramadol is difficult to get from pharmacies without a prescription in many African countries, it can very easily be acquired from the dark alleyways of Bamenda, Newtown, Freetown or Libreville and under the table mats of rat poison vendors.
Tramadol is not internationally regulated by the International Narcotics Control Board in obedience to the World Health Organization’s wishes.
WHO is primarily concerned that scheduling Tramadol could inadvertently limit the licit use of the medication especially in the developing world where effective pain relief is already hard to come by, says Dr Martins Ekor, associate professor of pharmacology at the University of Cape Coast.
“The general concern, therefore, is that the negative effects of an international control on Tramadol’s medical availability will cause more pain patients to suffer. Developing countries will be the ones most severely affected since controlled strong opioids are barely available and patients already suffer from severe under-treatment of pain.”
But this lack of international regulation means that production of Tramadol is cheap. China and India became leading exporters of Tramadol [paywall]after its original German makers lost significant parts of the patent. Generic drug manufacturers there have in the last few years upped the dosage of Tramadol to around 250 milligrammes from the recommended 50 and 100 milligrammes .
The absence of international control coupled with the fact that Tramadol is synthetic and does not require organic ingredients means that manufacturers in Guangzhou and Mumbai have no production limits, are not required to record how many pills they make or alert countries beforehand that the pills are headed their way. The factories keep vomiting the pills.
Out of sight, out of mind
After his forays into Tramadol for work purposes, Ali soon found that he had become dependent on it, taking it for pleasure at social settings and on days that he wasn’t working. Downing Tramadol with energy drinks or dissolving it into fruit juices (to subdue its bitter aftertaste) is viewed by many as a socially acceptable and more discreet way of getting high in comparison to the telltale aroma of cannabis residual smoke.
“I take it today, tomorrow if I don’t take it, I start feeling weak…,” he says of the withdrawal symptoms which include nausea. His tolerance level shrunk and so did his body, a result of dwindling appetite for food. He has also seen a fair share of overdoses.
“You will see somebody sitting there, then he freezes and hits the ground. About two, three minutes, then he wakes up. You just don’t know what happens then you are on the floor.” He attributes the deaths of friends to overdoses, possible when Tramadol is mixed with alcohol [pdf p.6]. Although he doesn’t know the right word, other things he describes as happening to friends could be seizures, a chief side effect of Tramadol intoxication [pdf p.6].
But stories such as Ali’s are not widely known because of many societal problems including a class divide. Several African countries are on the cusp of an epidemic but there are few indications the authorities have even heard of it. The Tramadol scourge has received very little public attention from mainstream media and African governments because the victims do not look anything like the friends or families of Africa’s upper class citizens. That is because majority of victims are those at the very bottom of the socioeconomic ladder who need to work many long hours to make ends meet, hence their reliance on Tramadol. They are the Okada motorcycle riders, the head porters and truck pushers in markets, illegal miners and bus drivers. As such, the overdoses, the seizures, the vomiting, the comas, and the cardiovascular collapses are out of sight and out of mind for Africa’s privileged class.
This situation has some parallels with the US’ own opioid crisis which had largely been under-covered as a major issue until the last couple of years. In October 2017, president Donald Trump declared the opioid crisis, a public health emergency, making available more resources for addiction treatment.
Instead, African governments remain fixated on criminalizing cannabis while Tramadol easily slips through borders to wreck citizens, many of whom had no prior experience with illicit drugs until a buddy recommended a ‘sex power booster’.
A war on Tramadol?
Some African governments are slowly starting to pay attention. Because taking Tramadol without a prescription is not illegal in many countries, there has been a spike in the seizure of illegal consignments and arrests of street peddlers.
“We have put it under our national laws. We have added Tramadol to the list of scheduled drugs that is how come you need authorization to bring it in [and importers] have to report on utilization,” says Olivia Boateng, head of Tobacco and Substances of Abuse at Ghana’s Food and Drugs Authority. Earlier in March, the country’s minister of health told MPs new restrictive measures were in the works, including “[collaborating] with the Pharmacy Council to restrict Tramadol display on the shelves of community pharmacies by putting them under lock and key.”
Bureaucracies like this—similar in Nigeria and Egypt—are exactly why the World Health Organization (WHO) has repeatedly shied away (on five separate occasions [pdf p.8]) from “scheduling” Tramadol, a move which would mean adding it to the list of internationally regulated opioids.
Aside from a fear of shortage for clinical practice, the WHO have taken this position because they remain convinced that “Tramadol has a low abuse potential” [pdf p.20] compared to other opioids despite new studies suggesting orally ingesting Tramadol increases its efficacy (previous studies looked at injected Tramadol). A WHO-preview report in November still did not propose scheduling Tramadol [pdf p.28].
The intransigence of the global health body means that combating the illicit Tramadol trade is hard. Although national bureaucracies ward off illegal shipments, it doesn’t mean countries such as Ghana, Nigeria and Egypt are insulated. The pills are simply shipped to ports in nearby Benin and Libya for onward distribution.
However, Professor Ekor is unconvinced that scheduling Tramadol is the panacea to the current abuse on the continent. While the WHO digs its heels in, Professor Ekor believes African governments especially those in ECOWAS, need to increase regional and international cooperation to detect and avert the diversion of Tramadol so that they do not end up in the wrong hands.
“[The situation] requires the implementation of targeted local measures to stop illegal activities…Therefore, a consistent implementation of local/regional actions and careful monitoring of the abuse situation will be more appropriate and effective in curbing the non-medical use of not just Tramadol but also other drugs or substances of abuse rather than international control.
There is also the need for medical intervention to help addicts wean themselves off the pills. For now, the likes of Ali, after seeing the pernicious effects of recreational Tramadol, are taking personal responsibility for their detoxification. He left the Timber Market job, changed friends and tries to stay away from places where he knows the red and green pills are sold at less than 25 cents.
But without a structured regime of rehabilitation, it is difficult to see how successful this self-journey will be for Ali, by his own admission “Tramore is too sweet, it is something when you take it, life is so good.”